Monday, March 28, 2016

Canine with Distended Belly; Splenectomy. Costs, Advice, Tips, and Why Immediate Surgical Intervention Is Critical.


This is Buddy. 

He is like most of the Jack Russell Terriers that we see in rural Maryland. He is fierce, brave, obstinate, and incorrigible. He is also unapologetic about all of this. He is a big personality in a small football sized package. He is the quintessential JRT. There are a few breeds that follow the breed specific personality test to the  letter; JRT's are that breed. They go full tilt full time and they want, need, or desire few things. It is a short list of "likes" and a long list of unmatched indifference. To love one you have to own one, to understand one you have to live with one.

Buddy is a fit muscular pup.
Can you appreciate the "roundness" to his belly?

Rather suddenly his parents noted that his belly was getting mysteriously bigger rather quickly. 

Should this happen to your dog you should go your vet as quickly as possible, OR, you could visit me at Pawbly.com and ask me what might be going on?

At Pawbly.com I am first going to tell you to head directly and immediately to the vet. Any vet, anywhere as this can certainly be a life threatening emergency.

Then I am going to answer as follows;
There are a few things you need to be worried about..

1. Something is leaking. Maybe blood? Maybe fluid. All are bad.

2. Something is expanding. Maybe the stomach (gastric) is inflating like a balloon? This is called dilatation. If that balloon twists it is called volvulus. If this happens these organs can become strangulated, this is like placing a string that is too tight around your finger. If not treated and relieved quickly this tissue dies. We all need a stomach. GDV can kill your dog in minutes to hours.

3. Something inside is growing. After adulthood is reached your organs aren't supposed to keep growing. In almost all cases that growing thing inside is not supposed to happen. Cancer is the most common cause of abnormal growth.

4. The abdominal wall can be stretching due to muscle loss,, but this is usually a slow gradual process. Think diabetes, Cushing's disease, hypothyroidism.

Now some of these cases these pets are simply getting fat. But fat is not a round basketball just got inflated in the belly.

Buddy is not fat.. Buddy is in crisis for something else.. Where do you go after the examination ($50 at Jarrettsville Vet) confirms your burgeoning belly suspicion?

A radiograph is the best way to decide which of the above Buddy has going on. ($100-$150 at JVC).


And there it is.. well, maybe not a basketball,, but it is a big round mass in Buddy's belly. 


After the radiograph was taken it was time to make some decisions. Up until now every vitally needed diagnostic has been done. You need to do these two things if this happens to your dog. I also should mention that the radiographs allowed us to assess the chest for evidence of metastasis. This piece of information is vital to the dogs prognosis moving forward. If there are mets in the chest the surgery will likely not change the prognosis or lifespan. 

The next decisions and steps are the ones filled with question, doubt, and intense scrutiny for clients.

Here's my advice on where to go from here;

1. Listen to your dog. Buddy was still rambunctious and barking at every passing dog. Buddy was still behaving like Buddy. In other words, Buddy thought he was perfectly fine. Huge prognostic indicator for a likely successful surgery. Do surgery on these dogs. Don't sit there thinking about worst case scenario. 

2. Be prepared for a financial hit. These happen to every dog that lives long enough. Every pet owner should have pet insurance for these situations, OR, a pet savings account. I recommend $1,000 for each pet. If you do not have this have a way to get access to this; a friend, a vet who trusts you, etc.

3. Start strategically planning the next few scenarios. Here is how I approach these cases with my clients; I want to get as much information as possible pre-operatively. This includes blood work ($170). I also want to do an ultrasound ($200) to "see" what the rest of the internal organs look like. If there are other lesions throughout the abdomen the prognosis is more guarded. 

4. Here's what my reality for these cases is;
I am NOT GOING TO SPEND SO MUCH OF MY CLIENTS MONEY THAT THEY CANNOT AFFORD SURGERY. I sit down with my clients and discuss what everything costs and what I want to do with the money they are spending on the information I am gathering. Nothing in the world drives me to the brink of insanity than talking to a client who has exhausted all of their resources on diagnostics and now cannot afford to treat their pet. There is no sense spending money to get a diagnosis if the treatment then becomes unattainable. I consider it unethical and reprehensible.

We suspected that Buddy's spleen was the culprit and that spleen needed to be removed ASAP! 

If you do not do surgery these dogs will very likely die of internal blood loss. 

The estimate for a splenectomy at JVC is $1000*. Buddy's parents did not have $1,000. We did what we always do in these cases. We discuss with our clients how we can get them the help their dog needs. This is the difference between JVC and too many other clinics. We will help your pet get back out the door. We have multiple options to help insure this. For Buddy's family a deposit and a payment plan through our good friends at Vet Billing Solutions were his answers. 


Buddy's spleen was the only thing you could see in his belly when we opened him up. It never ceases to amaze me how large a tumor can get and how incredibly resilient these patients are. When it comes to splenic tumors a few things are key;
  1. Get it out as soon as it is discovered. The spleen is essentially a blood sac. It loves to bleed, even when it is happy and healthy, if it has even the tiniest bit of trauma. BUT, when it is an abnormal mass of tissue it really, really, likes to bleed. A bleeding tumor, especially in the spleen, is ticking time bomb. 
  2. Get as much information as possible. radiographs, blood work (full chemistry, CBC, PT/PTT), and ultrasound are super helpful.
  3. Buddy was happy and acting oblivious to his tumor. This is the best prognostic indicator I ever hope to have.



Have an excellent surgeon and support staff. I don't say this often. In my heart I love being a small town quiet rural practice, BUT, I also have a stacked exceedingly capable veterinarians and staff. At JVC we can do almost every emergency surgery on almost everyday. When it comes to picking a vet to call your own, remember to ask about the dark days that may lie ahead. I know of many small practices that either do not, or will not, do emergency surgeries. There are too many times where the cost to go to a specialist prohibits care.* 


When I am about to do an exploratory surgery on a patient I ask my clients to be standing by a phone. Here's why;
Closing.. with a big sigh of relief!
I am never really sure what I am going to find until I look inside that patients abdomen? In some cases I have found widespread disease that was not evident in the pre-op work-up (most of the time we had to skip these due to finances), and in others the mass is not resectable (cannot be safely removed). If the patient cannot be saved by the splenectomy I want to discuss whether it is fair to wake them up?

The very dark red at the 9 to 11 o'clock position is normal spleen tissue.
Everything else is tumor.

The most common presentation of dogs in need of a splenectomy are weak, lethargic, pale, internally bleeding, and teetering on the brink of death. These cases require quick confirmation of the diagnosis and surgery.



Buddy is a 20 pound dog who had a 3.25 pound splenic mass. That's enormous on anyone's scale. Buddy did very well through surgery and woke up calmly, quietly and effortlessly.

Buddy returned the next day his normal bull headed dominant self. He also had a beautifully quiet incision.


And now a trim waistline.







Closing Notes;
  • There are some surgeons who perform routine gastropexy after splenectomy to prevent post-op GDV. It is something you should discuss with your vet pre-operatively.
  • Post-operatively these patients should be monitored very closely. Ideally, at a 24 hour facility. ECG, blood pressure, PCV/TP. Transfusions may be needed in cases where blood loss was severe.
It is my belief that any and all abdominal masses warrant an internal look before euthanizing. We are reminded daily that life is full of miracles and second chances. I know it is hard to hear, scary to admit, and expensive to treat but 50% of these pets are curable! Take a leap, look inside, and get the spleen out fast... sometimes fate will deal you a good hand and often life will remind you it is worth fighting for.


Buddy's cost of care at JVC was as follows;

Presentation;
  • Exam $50 and radiograph $100.

Surgery Day;
  • pre-op chemistry w/ CBC $50
  • injectable NSAID $20
  • injectable antibiotic $30
  • iv catheter and fluids $80
  • splenectomy $350
  • surgical supplies $75
  • anesthesia $200
  • post-op analgesia and antibiotics $40
Total cost $1050. 

Many thanks to Vet Billing Solutions for helping us provide a way to make Buddy's surgery affordable to his family.

*Estimates for this surgery at an emergency clinic can range from $1500-$3500.

Related Blogs;




If you have a pet question, or want to share your pet knowledge, please join the free online pet information exchange network that is dedicated to helping pet parents learn about how to best care for their pets. Pawbly.com is free to use and open to anyone who loves pets.

I can also be found at the clinic, Jarrettsville Vet, in Jarrettsville Maryland. We post our prices and fees every year and we have a wonderful Facebook page. I am also on Twitter @FreePetAdvice.

Saturday, March 5, 2016

My Veterinary Rescue Shaming and The Frank-Starling Law.

Warning: This blog o' mine can become my sounding board. My vessel to vent. And, yes my therapy couch as I continue to try to keep my chin up and press on... I share my experiences, thoughts, and yes, even my stumbles along this journey as a way to grow, learn, and provide my burgeoning heart of emotional baggage a place to rest.

My Magpie. 
We live in a competitive consumer driven society. Subsequently there is intense contentious debate about pricing in veterinary medicine. I have added my own thoughts, and I do recognize that many people believe that the veterinary profession is pricing our clients out of their ability to care for their pets/our patients. I hear it all too often from an angry, frustrated, desperate finger pointed harsh protest about "excessive cost of care" and" how this is the reason for the current state of pet welfare."

None of us want to be humiliated or felt as if we have been taken advantage of. It is an emotion encountered when you allow yourself to be vulnerable and/or wear your emotions on your sleeve. It is a common characteristic for those of us who choose a profession in healthcare.

In medicine we call it "shaming."

After a decade in private practice, lots and lots of pro bono work (which I used to take great pride in and even boast about) for both clients, rescues, and rescue volunteers, and now I am feeling lost. The rescue people I hoped both appreciated and needed my skills are seeking care "at their regular vet" (what am I chopped liver?), or complaining about my excessive "regular costs." I now see why it is so common for other vets to just say "No" when asked for free/discounted care.

The trick to keeping yourself adequately armored from shame, guilt and humiliation is to be just far enough from the situation as to appear resistant to the emotional tactics employed when the dilemma presents.  I am seemingly unable to embrace or accept this concept.

Magpie relaxes after a hard day of relaxing.
The clinic I own has been or become the veterinary care provider to a few local rescues. We provide whatever care needed and provide our vet services for free and all goods at cost. It is the best deal I could even propose to provide.

As a practice owner it always appears that the need exceeds the ability to help everyone who asks. How do you manage this fact on a day to day basis? I think that most vets just start saying "No" because they feel they have to. If we cannot meet the need why even start? Rescues and shelters therefore believe vets have turned their backs on what the foundation of our profession stands for.

My current debacle is trying to remain interested in helping these rescues simply for my own peace of mind. The expectation of accolades or appreciation is being crushed by recent events.

My Joe and Wren
"Give me your clinic time and discounts but I'm taking my personal pets elsewhere."



Winter snow day 2016, Jekyll and Charleston. Both rescues..

Situation Number 1;
RV 1 (Rescue Volunteer 1);  "Hello, yes, I'm calling to get a refill of the xx medication for my dog."

Me; "OK, please hold, while we check your file." short pause on hold. "Umm, Ms. T, it seems we forwarded your pets records to another clinic? Is that correct?" (I swear I should know better by now than to answer my own phone lines..)

RV 1; "Yes, I don't come to your clinic anymore because the wait time to see the vet is too long. But I haven't been to the new vet yet and I don't want to pay them an office visit if I can get it from you guys now."

Me; "So you are telling me that you want to continue to bring rescue dogs here, but you don't want to wait while we take care of other rescue dogs? And now we are supposed to provide medications because it will save you money and from having to go to your new vet?"
Angry click and multiple Facebook berated comments about how we are all about the money follow. Along with an apology from the rescue founder when she caught wind of it.

Magpie proof reads
Situation Number 2;
How about answering to the rescue founders who bring their pets to other clinics who never help the rescue pets in need. That's a hard one to accept. Would it be so hurtful if their own vet participated in the spay/neuter clinics we do? Maybe not?

The reason I sleep in, Wren under the blankets, Oriole provides cover.

Situation Number 3;
Open letter from a personal friend and devoted long time rescue employee;
"Dear Veterinarians of the World,
I'd like to make a request. Until you work very faithfully and with utmost dedication at a rescue or a shelter, can you please not bad mouth ALL shelters and rescues ever? I find this very (very, very, very, very, EXPLICITLY...) frustrating.
We don't live in an ideal world. We're just trying to save lives.
heart emoticon,

PS. I absolutely LOVE all of the vets I know personally. It's the vets I hear about 2nd and 3rd hand who seem to criticize rescues and shelters the most. I'd love to have a conversation with anyone who thinks negatively of rescues or shelters...." XXXtech

Reply from another fellow RV (rescue volunteer);
"Really? How can you not think there is a problem with vet pricing, please 350.00-400.00 for a feline dental? I'm sorry if that isn't excessive , I don't know what is. Societal problem, no it's not a societal problem, not everyone has the means to put out that kind of money for routine care let alone if one of them gets sick. Most don't. You are doing a wonderful service to the community and the animals and don't ever forget how phenomenal you are, we need more people like you who dedicate their lives to the welfare of these animals and you should never let their ignorant comments affect the outstanding job rescues and shelters such as XXX does."

(personal note to self,, stop answering my clinics phones and reading posts on social media)

Me;
"We need to talk about this rant! If you can figure out a way to keep your cat quiet and still while I clean their teeth I would be happy to shave $150 off that price. It's not excessive. I promise. If you and the rest of the world would kindly start brushing your pets teeth twice a day society won't have an excessively expensive pet dental problem. I am sad to see this."

RV
"No rant, just my opinion, and I will never be convinced that that price is justified. Maybe $200, but 350-400, please. this was my opinion that 350-400 for a dental is overpriced. I'm not comparing them to XXX's care, I've worked too many spay/neuter clinics to compare; by all means the quality of care is far superior at the vet than what you get at the shelter, but sorry, this is my opinion and we can agree to disagree if you'd like."


Me;
"You are welcome at the clinic anytime. I would be happy to show you where the cost goes. In many cases the old adage "you get what you pay for" applies. If I could provide it cheaper I would. We can agree to disagree and I will do my very best to not give up on providing excellent care at affordable prices even to the wonderful rescue people who seem to sometimes not appreciate it. Perhaps some will not believe me when I say this, but, if done correctly by someone trained to do it, a dental needs to have anesthesia, should absolutely have iv fluids, nerve blocks, and dental X-rays. Extractions if needed, and most dentals (I would say 70% plus) need them have to be done by a trained vet. Then a cleaning and polishing. The fastest dental is about an hour. There is absolutely no way this can happen for less than $300. If you want it to be a profitable clinic it starts at $400. I am sure there are people who balk at the extra price of non GMO fair trade organic food. Do I understand why it costs more? Yes, because I care to invest the time and attention in understand how my actions impact the world I live in. If you can find a $200 dental I promise I can find numerous short cuts that are detrimental to your pets health and safety. Being an educated and compassionate consumer takes work and a kind heart.

I am trying to be a vet who helps everyone and supports rescue. I care deeply about the people of XXX and those in my community. I hate to see all of the nastiness and division between us. I wish you all well in your efforts to help animals."

XXXtech reply;
This conversation has definitely taken a turn from what I originally intended. I'm with Dr. Magnifico. The costs are justified at full service vet clinics. They have staff to pay, overhead to think about, and they offer quality service. While rescues need to think about these things, we're at least lucky to raise money for necessary expenses through generous supporters. Veterinarians do not have that luxury. Often times at a low-cost clinic, certain things aren't done to save time and money. This isn't ideal, but sometimes it's the only option the animal/caretaker has and, in those instances, it's better than having the animal euthanized because a full service vet can't be afforded.
I see both sides of the coin. We do the best we can for our rescue animals, and also people in the community who cannot afford higher prices. On a personal note, I prefer to take my own pets to vet clinics for exams and certain procedures because I know that there's often a higher level of quality care that is offered.
I am lucky though in that I can utilize certain services at the rescue like low-cost bloodwork or at cost medicines. That's why having so many animals is at least feasible. Many people don't have this nice perk, so vet care can be quite costly.

Me;
I'm sorry XXXtech I know this wasn't what you intended the post to become. But it is important that we all talk to each other openly and honestly. It would have been very easy to walk away from this conversation and silently swear to myself to never help the ungrateful critics who ask for it. Alienating myself from those I know are trying to help animals in need just feeds the problem. I don't want to be part of the angry other side. So I struggle remain a part of the solution and see the good in all people. In rescue, veterinary medicine, and life this is a huge challenge.

Jekyll reminds me to keep a healthy perspective on life.

I had to do what I often find myself doing more often, I had to walk away. Leave the battle that was only going to divide us. I have to pull up my passionate opinions, roots, let go of the connections that cause pain, try to reinforce my insulation in a healthy manner, and not carry a burden that will only prevent me from that next furry face who needs me as much as I need them.

In the end I still struggle. I don't propose to know what the right answer for everyone else is. I know that I have to focus on the furry faces I am here to provide for. I cannot ask, look, expect, or even hope to get anything from anyone else. Shame, I have it, we all do, it is why we became vets, I just can't chose my path based on it. My heart is still on my sleeve, it always has been, always will be, and in the end I think it is the best part of me.. broken, bruised, resilient, over burgeoning, over taxed, and over abundant. For those of you who are in this boat with me remember the Frank-Starling Law, our hearts can increase their volume when there is an increased load. (Personal note; all of my cats are named after bird species. Next cat; 'Starling').

There are lots of us struggling with this shame on every side. The immensely over burdening need, the responsibility of every rescue/person/vet trying to save every pet and asking each other everyday to extend our necks, our pockets, our hearts, and give away another piece of ourselves. There is an avalanche of need. A tsunami of shaming.

Worst for me the rescues, the people I most closely bear my soul to, work tirelessly for and try to help above and beyond every other request, berate and remind me that if I am fragile, sensitive, wear my heart on my sleeve, or let someone, they can humiliate, hurt, and castigate publicly. It feels as if this is going to drive me to either turning a blind eye, or succumbing to the compassion fatigue that hides like a shadow behind every corner.

How can the one group of people that are supposed to most closely understand the burden of my heavy heart turn on me? I don't know. But, there is probably enough blame to burn down every compassionate effort and then we will still have to remind each other why we do what we do.

Magpie.
Found as a kitten with a broken ankle and adopted by us from the rescue above.
She is one of the lights of my life and why anything else matters.

End footnote; Judgments, criticism and and cruelty can be kept to yourself, I have enough that I provide myself, and, am still trying to find a place to stow them.

Related articles on Vet Shaming; Coping With Vet Shaming, Andy Roark, DVM, MS

My related blogs;

Economic Euthanasia

Carry Each Others Burdens.

The Profitability of Drive-Thru Euthanasia Clinics.

Can Veterinary Care Evolve With Our Clients?

Compassion Fatigue.

There Has To Be Mercy Before Money.

Never Surrender Your Voice.

What Are You Building?

Making Vet Care More Accessible.

Make a new furry faced friend every day

Please join me on Pawbly.com. Pawbly is an open free community based pet information exchange network.

If you  would like to discuss your pets care in person I am available for appointments at Jarrettsville Veterinary Center in Jarrettsville Maryland. JVC is open 7 days a week. JVC publishes our prices every year. The 2016 Price Guide can be found here.

I am also on Twitter @FreePetAdvice.